Audit and Feedback

Audit and feedback is an assessment of health care provided in relation to standards and guidelines. Through audit and feedback, data are collected on adherence of services provided to standards and linked to a process of feedback that may be directed to individual providers or health care teams. The feedback may include a comparison of individuals’ performance patterns with those of immediate peers, with aggregate performance data for large groups of providers, or with accepted standards. Feedback interventions assume that notifying individuals or groups about deviations from peer behavior or accepted criteria will lead to improved performance.

Audit and feedback processes may include peer review, supervisor assessment, clinical record or community or facility register review, adverse events audits, self-assessment, and accreditation surveys.

Peer-mediated strategies may include formal peer review, participatory guideline development, and team-based process improvement and problem solving. Peer review typically involves review of a provider’s performance by peers from the provider’s cadre (e.g., community health worker or midwife). Peer review uses the expertise, influence, and pressure of people in a provider’s social network to try to influence individual provider performance. Several studies have found that peer review is more effective in changing practice routines when applied as part of a broader quality improvement approach that includes participatory development of criteria, quality circles, and group discussion and feedback (Lin & Franco 2000).

Clinical audits are systematic reviews of registers or patient charts to determine the care given in relation to the standard of care; they are done by sites for monthly monitoring and conducted externally for data validation. Audit of adverse events and near-miss audits allow teams to reflect on, understand, and learn from rare, catastrophic or near-catastrophic events through peer review of cases that caused concern, affected patient safety, or resulted in an adverse outcome.

Self-audit or self-assessment may be conducted by an individual health care provider, often as part of a continuing education activity to reflect on his or her own performance strengths and weaknesses to identify learning needs and areas for improvement (Bose at al. 2001). Self-assessment also may be conducted by a team that reviews records for a facility or for all community health workers in a community to measure performance across all providers in the facility or community. Improvement collaboratives typically rely on monthly team self-assessment of compliance with standards to track the effects of changes made to improve care.

Because team-based peer review and support approaches tend to be directed at improving care in a facility as a whole rather than at the individual practitioner level, they may be more useful as part of strategies to achieve performance according to standards on an institutional level (Kim et al. 2000, Kelley et al. 2002). Regardless of the type of audit and feedback process used, it is important to keep in mind that audit and feedback alone, without action to correct problems, may not improve care, but can provide valuable insights into critical quality gaps to support change and solutions for improvement.

Text box: Improving Quality of Maternal and Newborn Care through

Community-Facility Micro-networks in Ecuador

The Essential Obstetric and Newborn Care (EONC) Micro-Networks Project in Cotopaxi, Ecuador, sought to reduce maternal and newborn mortality in the 21 parishes of the province with the highest poverty level. Parish-level micro-network teams, comprising community and social organization representatives, traditional birth attendants (TBAs), and midwives and doctors, met regularly (usually monthly) to plan and coordinate care for mothers and newborns in their parish and to find ways to improve both quality and coverage of EONC. TBA members of the parish micro-network teams actively searched for pregnant women in their communities, and then reported to the parish micro-network team during monthly meetings on the status of pregnant and post-partum women and newborns in their villages. TBAs received ongoing support during initial training sessions and subsequent monthly meetings to provide home-based, high-impact routine pregnancy and post-partum services; referred pregnant women to health centers for delivery; and learned to recognize, screen, and refer to the health center any women and newborns with risk factors or danger signs. Parish micro-network teams used project-wide standard referral coupons with culturally adapted pictorial images that TBAs could easily mark off at the time of a referral to indicate the reason (e.g., fever or prolonged labor).

Parish micro-network teams used improvement approaches to adapt and change facility childbirth services to be more responsive to the needs and preferences of indigenous women and their families. For example, as a result of project activities, women are now actively supported to include their companion of choice during labor and delivery and to give birth in their preferred position (usually kneeling in the arms of their partner).

In addition to increasing access and use of high-impact services, the project also worked with facility-based quality improvement teams to conduct monthly audits of their compliance with Ministry of Health EONC quality standards and implement improvement actions to correct deficiencies. The project also assessed the quality of home visit activities conducted by trained TBAs, through observation of live or simulated home visit sessions with the use of a mannequin and a checklist. TBA compliance with post-partum counseling standards increased from 3% at baseline in 2010 to an average 70% compliance with post-partum counseling standards in the last quarter of 2012.

Source: Center for Human Services, 2013